The title may sound like a trick question. You probably thought, “Of COURSE it matters! Why wouldn’t it?” Well, a newly published British study suggests the choice of treatment does not make a difference in mortality rates. The research by Hamdy, et al. (2023) compares long-term mortality rates of radical prostatectomy (RP), radiation, and Active Surveillance (AS).^[i] The primary outcome was PCa-specific mortality (death due to PCa). Also reported were rates of all-cause mortality (death from any cause), metastases, disease progression, and going on hormone therapy.

According to a CNN news story, the study says that “most men who are diagnosed with prostate cancer can delay or avoid harsh treatments without harming their chances of survival.” In other words, it supports the idea that aggressive treatments like RP or radiation don’t confer a significant survival advantage for most patients; it doesn’t really matter whether you have surgery, radiation or AS because the odds of dying from your PCa are roughly the same. Let’s look at the study’s data.

What the numbers show

Here is a summary of the data:

	RP	Radiation	AS
Death from PCa	2.2%	2.9%	3.1%
Death from any cause	21.7% of patients died, rates similar between groups
Metastasis	4.7%	5.0%	9.4%
Disease progression	10.5%	11.0%	25.9%
Hormone therapy	7.2%	7.7%	12.7%

The authors also note, “In the active-monitoring group, 133 men (24.4%) were alive without any prostate cancer treatment at the end of follow-up.”

An important study

Three elements make this a noteworthy study. First, it’s long-term, with an average follow-up duration of 15 years (range 11-21 years). This is important, because many studies have a much shorter follow-up period, whereas the Hamdy report tracked patients over the long haul. Second, the 1610 men involved were randomly assigned to either RP, radiation, or AS; this eliminates the element of bias which can skew study results. Third, over 1/3 of the men had intermediate-to-high-risk disease at diagnosis, though it was a later analysis that retrospectively determined this—and it did not affect the statistical analysis.

Key point

The patients in this study were diagnosed between 1999-2009. The standard of care during at that time put patients in the line of fire for overdiagnosis and overtreatment. Patients whose PSA test suggested PCa were rushed to TRUS biopsy, a diagnostic test that tends to overdetect insignificant PCa (not likely to become life threatening) and underdetect significant PCa that poses a greater risk. Back then, patients had a limited range of treatments: RP, some form of radiation, or Watchful Waiting (WW). Both surgery and radiation left untold numbers of men with urinary, sexual or bowel side effects, many of which ended up being long-term or even permanent. Because of the damage done by such treatments, the Hamdy study was initiated in part to determine if most men could safely avoid harsh procedures.

A LOT has changed since the study began recruiting. Today’s diagnostic tools, especially multiparametric MRI (mpMRI) and genomic testing, provide much more accurate portraits of a patient’s PCa. For men who qualify for AS, and are comfortable with PCa living in their body, the caliber of monitoring is hugely improved thanks to those same tools—so AS is safer now than it was then.

Most of all, we have a bigger range of treatment options, including focal treatments that destroy the tumor with little-to-no impact on urinary, sexual and bowel function. The combination of more precise diagnosis, along with expanded treatment options, allows individualized treatment plans. In turn, this means higher success with lower side effect rates.

The 1610 men in the study are owed a huge debt of gratitude for agreeing to be randomized to RP, radiation or AS. They were neither matched with a treatment based on clinical factors, nor free to decide which treatment they preferred. Thanks to the gift of themselves for research purposes, the study authors were able to reassure newly diagnosed patients that PCa-specific fatality rates are low regardless of treatment choice.

On the other hand, if you know your cancer isn’t likely to kill you, why not explore treatment options that destroy the cancer (freedom from anxiety) while preserving your manhood (freedom to enjoy life fully)? In this respect, the prostate cancer treatment you get matters. In fact, it matters a LOT!

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Hamdy FC, Donovan JL, Lane JA, Metcalfe C et al. Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med. 2023 Mar 11.